HOSPITAL CARE COVERAGE – SUMMARY OF BENEFITS - Cigna

1 887511 08/17 2017 Cigna . Offered by Life Insurance Company of North America (a Cigna company) HOSPITAL care COVERAGE provides a fixed benefit according to the schedule below when a Covered Person incurs a HOSPITAL stay resulting from a Covered Injury or Covered Illness. Who Can Elect COVERAGE ? You: A regular full-time Employee of a participating Cigna company, regular part-time Employee of a participating Cigna company regularly scheduled to work at least 28 hours each week who is working in the United States, the District of Columbia, Puerto Rico, Guam or the Virgin Islands or are designated by the Plan Administrator as an eligible US expatriate.

2 Or a part-time Employee of a participating Cigna company regularly scheduled to work at least 24 hours, but less than 28 hours a week as of December 31, 2013, who remain continuously employed, excluding hourly, casual, interns and other Employees of a participating Cigna company not classified as regular full-time or part-time in the Cigna personnel records. Residents in Vermont are required to work at least hours to be eligible. Excludes employees residing in the state of Washington. Your Spouse*: Is eligible as long as you apply for and are approved for COVERAGE yourself. Your Dependent Child(ren): Birth to 26, as long as you apply for and are approved for COVERAGE yourself.

3 *For purposes of this brochure, wherever the term Spouse appears, it shall also include Domestic Partner registeredunder any state which legally recognizes Domestic Partnerships or Civil Unions. Your Spouse must be age 18 or older to apply if evidence of insurability is required. Additional information is available from your Benefit Services Representative. Schedule of BENEFITS The benefit amounts shown in this SUMMARY will be paid regardless of the actual expenses incurred. BENEFITS are only payable when all policy terms and conditions are met. Please read all the information in this SUMMARY to understand the terms, conditions, exclusions and limitations applicable to these BENEFITS .

4 See your Certificate of Insurance for more information. Benefit Waiting Period: None Hospitalization BENEFITS Plan 1 HOSPITAL Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 90 days. $1,000 per day HOSPITAL Chronic Condition Admission No Elimination Period. Limited to 1 day, 1 benefit(s) every 90 days. $50 per day HOSPITAL Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 90 days. $100 per day HOSPITAL Intensive care Unit (ICU) Stay No Elimination Period. Limited to 30 days, 1 benefit(s) every 90 days. $200 per day HOSPITAL Observation Stay 1 hour Elimination Period.

5 Limited to 72 hours. $100 per 24-hour period Prepared for: Cigna Corporation Class 1 Employee-Paid HOSPITAL care COVERAGE SUMMARY OF BENEFITS Group HOSPITAL Indemnity 887511 08/17 2017 Cigna . Employee s Cost of COVERAGE : Tier Bi-Weekly Rates Monthly Rates Employee $ $ Employee & Spouse $ $ Employee & Child(ren) $ $ Employee & Family $ $ Costs are subject to change, and may be different if certain BENEFITS or riders are not available in certain resident states. NOTE: The following are some of the important policy provisions, terms and conditions that apply to BENEFITS described in the policy.

6 This is not a complete list. See your Certificate of Insurance for more information. Benefit Amounts Payable: BENEFITS for all Covered Persons are payable at 100% of the Benefit Amounts shown, unless otherwise stated. Late applicants will require medical evidence of insurability. Benefit-Specific Conditions, Exclusions & Limitations ( HOSPITAL care ): HOSPITAL Admission: Must be admitted as an Inpatient due to a Covered Injury or Covered Illness. Excludes: treatment in an emergency room, provided on an outpatient basis, or for re-admission for the same Covered Injury or Covered Illness. HOSPITAL Chronic Condition Admission: Must be admitted as an Inpatient due to a covered chronic condition and treatment for the covered chronic condition must be provided by a specialist in that field of medicine.

7 Excludes: treatment in an emergency room, provided on an outpatient basis, or for re-admission for the same Covered Injury or Covered Illness (including chronic conditions). HOSPITAL Stay: Must be admitted as an Inpatient and confined to the HOSPITAL , due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the ICU Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. HOSPITAL stays within 90 days for the same or a related Covered Injury or Covered Illness is considered one HOSPITAL Stay.

8 Intensive care Unit (ICU) Stay: Must be admitted as an Inpatient and confined in an ICU of a HOSPITAL , due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the HOSPITAL Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. ICU stays within 90 days for the same or a related Covered Injury or Covered Illness is considered one ICU stay. HOSPITAL Observation Stay: Must be receiving treatment for a Covered Injury or Covered Illness in a HOSPITAL , including an observation room, or ambulatory surgical center, for more than 23 hours following the 1 hour elimination period, on a non-Inpatient basis and a charge must be incurred.

9 This benefit is not payable if a benefit is payable under the HOSPITAL Stay Benefit or HOSPITAL Intensive care Unit Stay Benefit. Common Exclusions and Limitations: Exclusions: In addition to any benefit-specific exclusion, BENEFITS will not be paid for any Covered Injury or Covered Illness which, directly or indirectly, in whole or in part, is caused by or results from any of the following (unless otherwise provided for in the policy): (1) intentionally self-inflicted injury, suicide or any attempt threat while sane or insane; (2) commission or attempt to commit a felony or an assault; (3) declared or undeclared war or act of war.

10 (4) a Covered Injury or Covered Illness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, we will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days; (5) voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage; (6) Operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it.